Clinical Documentation Improvement (CDI)

Without a doubt, electronic documentation has significantly changed the working life of CDI specialists. It starts with the tools CDI specialists have traditionally used – color-coded review forms, sticky notes and “hard charts” are now virtually obsolete. Now, review occurs in the EMR and can begin the moment a physician enters an electronic note. Queries can also be sent and tracked electronically. In an electronic workflow, CDI specialists don’t even need to be in the same city or country as the physicians to perform their duties.

But the migration from paper to electrons has not marginalized the value of CDI specialists. More than ever, an effective CDI program is integral to developing a successful electronic documentation workflow.

Electronic workflow tools enable an EMR system to serve as the hub of almost any data-driven activity a hospital performs. With instant access to any document in the EMR system, everything from documentation review and physician query to patient handoffs and quality reporting initiatives can be performed concurrently.

But an EMR is not a magic wand. Users across your health system rely on the same data from the same documentation at the same time. In such an interconnected environment, all the EMR system functionality in the world won’t overcome incomplete, inconsistent or inaccurate documentation. Capturing the right documentation at the point of care is absolutely critical to improving clinical productivity, patient outcomes and financial performance.

The Salar Solution: Enabling a True Front-End CDI Workflow

With Salar, your hospital’s CDI program can fully integrate with the front end of an electronic documentation workflow to ensure accurate, comprehensive, high-quality data is captured at the point of care. TeamNotes, our electronic physician documentation solution, enables physicians to select codes at the point of care. Combined with our TAP Charge Capture tool, which integrates with internal and external billing systems, Salar helps you achieve a front-end computer-assisted coding solution that drives substantial benefits across your health system:

• Achieve Broader Physician EMR Adoption - Physician participation is vital to the success of any EMR implementation. Unfortunately, many electronic documentation solutions simply make life too difficult for its most important users. By delivering computer-assisted coding and CDI capabilities on the front end of the workflow, TeamNotes helps physicians capture information in the EMR as efficiently, accurately and intuitively as possible.

• Identify New Revenue Opportunities – With faster, more accurate communication across the care team, hospitals are able to complete charges faster and shorten billing cycles. By continuously improving the accuracy and completeness of the data captured at the point of care, a Salar-driven front-end CDI solution can help increase Case Mix Index and support additional reimbursement opportunities.

• Improve Documentation Quality at the Point of Care - With Salar, your front-end CDI program becomes a seamless loop of quality improvement that spans every documentation touchpoint. By identifying improvement opportunities across the workflow and implementing them directly at the point of care, front-end CDI supported by Salar helps hospitals achieve higher-quality documentation quickly and easily.